Termination of Pediatric Resuscitation – the Elephant in the Room, Part 1

The picture of the grieving emergency physician who “couldn’t save” a patient went viral in common media. However emergency physicians know that their emotions run even higher after we “couldn’t save” someone because we are the “final call”, the decision maker, the one that says “stop…right now.” That responsibility in itself can make what might have been already a futile case feel gut-wrenching – especially when it involves a child. As pediatric emergency medicine physicians, we will all be faced with the decision to terminate a resuscitation following cardiac arrest. Clinically, this may be an obvious decision. However, this decision emotionally and ethically looms like an elephant in the resuscitation room, until it is the last one at the bedside…and then it will often follow you home.

The American Heart Association, the Neonatal Resuscitation Program, and the European Resuscitation Guidelines (Pediatric) all describe discontinuing support in the newborn without signs of heart rate after 10 min of resuscitation. However none of these organizations describe specifics for discontinuation of support in children. A 2015 study in the Annals of the American Thoracic Society addresses this issue in children and adults with the concept of “CEASE.” CEASE stands for: Clinical features that predict survival; Effectiveness of resuscitation efforts; Ask the other clinicians present; Stop resuscitation efforts; Explain what has happened to the family.” Though this article is vague in its recommendations, the value in it is the mantra like pneumonic. In the hectic setting of a pediatric resuscitation, reviewing the CEASE mnemonic can provide a framework for discontinuing resuscitation.

In the Part 2 follow-up post, I will discuss evidence based recommendations as well as personal experience following the termination of resuscitation in a pediatric patient.